Pharmacy Practice, Caritas College of Pharmacy.
Antibiotic resistance has emerged as a global public health crisis, posing a significant threat to the efficacy of antibiotics in treating infections. In order to determine the root causes of antibiotic misuse and resistance in these disparate contexts, this study compares the prevalence of antibiotic resistance and antibiotic use patterns between Kerala, India's urban and rural populations. Using a cross-sectional observational design, the study polls 258 people who have taken antibiotics within the last six months and range in age from 18 to 55. Structured interviews and questionnaires were used to gather data on topics like antibiotic resistance awareness, disposal techniques, adherence to recommended courses, procurement practices, and antibiotic-related behavioural patterns. The results show that although both urban and rural populations typically obtain antibiotics through formal healthcare systems, self-medication, antibiotic sharing, and inappropriate disposal are more common among rural populations. Although both populations displayed knowledge gaps, particularly with regard to the significance of finishing antibiotic courses and safe disposal techniques, awareness of antibiotic resistance was greater in urban areas. The study also found that the use of antibiotics in animals and inappropriate antibiotic disposal are contributing factors to the escalating issue of antimicrobial resistance. The findings highlight the necessity of focused interventions, such as increased public awareness campaigns, more stringent regulatory enforcement, better access to healthcare, and instruction on how to properly dispose of antibiotics. Antibiotics' efficacy for upcoming generations can be maintained by addressing these issues, which will also lessen the emergence of resistant strains and stop antibiotic abuse. This study emphasizes how crucial context-specific tactics are in addressing antibiotic resistance in a range of demographic contexts.
The global rise in antibiotic resistance represents a critical challenge to public health systems. Antibiotics, hailed as one of the greatest medical breakthroughs, have become increasingly ineffective against certain bacterial infections due to the evolution of resistant strains. This phenomenon is particularly concerning in diverse population settings such as urban and rural areas, where antibiotic usage patterns, access to healthcare, and socioeconomic factors vary significantly. [22,21] This thesis, titled "A Comparative Study on Antibiotic Use and Resistance Patterns among Urban and Rural Populations," seeks to analyse these differences to understand the underlying causes of antibiotic resistance and propose targeted solutions. Through quantitative and qualitative methodologies, this study will shed light on the behavioural, socioeconomic, and systemic influences that shape antibiotic use and resistance in diverse settings.
1.1 Antibiotic Resistance
Antibiotic resistance occurs when bacteria evolve mechanisms to resist the effects of drugs designed to kill them, rendering treatments less effective or entirely ineffective. The World Health Organization (WHO) identifies antibiotic resistance as a major public health threat, exacerbated by improper antibiotic use, unregulated sales, and inadequate public health policies (WHO, 2020). The economic and social burden of resistant infections is profound, leading to increased healthcare costs, prolonged hospital stays, and higher mortality rates.[18]
1.2 Reasons for Antibiotic Resistance
Several factors contribute to the emergence and spread of antibiotic resistance. These include the overuse and misuse of antibiotics in humans and animals, lack of stringent regulations, and gaps in public awareness. Inadequate diagnostic capabilities in healthcare settings also lead to empirical prescribing practices, further contributing to resistance.[16] Poor sanitation and insufficient infection control measures in both urban and rural areas amplify the spread of resistant bacteria.
1.3 Use in Urban and Rural Populations
Urban and rural populations exhibit distinct patterns of antibiotic use due to disparities in healthcare access, education, and socio-economic conditions. Urban areas, characterized by better access to healthcare, often see higher rates of antibiotic overprescription, driven by patient demand and the ease of availability. On the other hand, rural populations, facing limited access to qualified healthcare providers, frequently resort to self-medication or reliance on untrained practitioners.[17] This dichotomy in antibiotic usage behaviours highlights the need for tailored interventions.
1.4 Antibiotic Resistance in Urban and Rural Populations
Research indicates significant differences in antibiotic resistance patterns between urban and rural populations. Urban areas often exhibit higher resistance rates due to increased antibiotic consumption, while rural areas face resistance stemming from incomplete or improper use. Moreover, socio-economic factors such as poverty, lack of education, and cultural practices in rural settings exacerbate the problem.[21] These variations underscore the importance of context-specific approaches to combating antibiotic resistance.
1.5 Use of Human Antibiotics in Animals
The use of antibiotics intended for humans in animal agriculture is a critical factor in the development of resistance. Antibiotics are commonly used in livestock not only for disease treatment but also for growth promotion. This practice contributes to the selection of resistant bacteria, which can transfer to humans through the food chain or environmental contamination. Recent studies highlight the need for stricter regulations and alternative practices in animal husbandry to mitigate this risk.[19]
1.6 Reasons for Irrational Use
The irrational use of antibiotics arises from multiple factors, including lack of awareness, cultural misconceptions, and economic constraints. In many developing countries, antibiotics are often dispensed without prescriptions, driven by consumer demand and inadequate enforcement of regulations.[20] Educational campaigns and stricter enforcement of existing policies are critical to addressing these challenges.
1.7 Recent Development of Antibiotics
Recent years have seen efforts to address the stagnation in antibiotic development. Researchers are exploring novel antimicrobial agents, including bacteriophage therapy and antimicrobial peptides, as well as strategies to repurpose existing antibiotics. However, the slow pace of development and the high costs associated with bringing new drugs to market remain significant barriers.[22]
1.8 Dispensing Practices in India
India faces unique challenges in regulating the dispensing of antibiotics. Despite government initiatives such as the "Red Line Campaign," which aims to educate the public about the dangers of misuse, antibiotics continue to be sold without prescriptions in many areas. Recent studies emphasize the need for robust enforcement of drug regulations and improved healthcare infrastructure to combat irrational dispensing practices.[15]
2. Aim And Objective
2.1 Aim
To compare the patterns of antibiotic usage and the prevalence of antibiotic resistance among urban and rural population.
2.2 Objectives
1. To compare the antibiotic use patterns and resistance prevalence.
2. To examine the demographic, socioeconomic and healthcare system factors.
3. The study evaluates the effectiveness of current antibiotic use and resistance management regulations in urban and rural areas.
3. MATERIAL AND METHOD
3.1 Study Period
The study was conducted over a period of 3 months.
3.2 Study Population
The study was conducted among 260 individuals from both urban and rural population in Kerala, India.
3.3 Study Design
It was a cross-sectional observational study conducted among urban and rural population from Kerala.
3.4 Study Tool
A well-structured validated questionnaire was used for the study. The questionnaire was pretested and verified for errors.
3.5 Inclusion Criteria
The study included adults aged 18-55 years, both male and female, who have used antibiotics within the past 6 months and have provided informed consent to participate in the study.
3.6 Exclusion Criteria
The exclusion criteria for the study included individuals under 18 years of age, those above 55 years, patients receiving palliative care, as well as pregnant or lactating women.
3.7 Study Tool
A questionnaire was prepared based on evidence from existing studies and careful examination of the literature survey and features used in them. The questionnaire consisted of a total of twenty-four questions. First section of the questionnaire included five questions on demographic and personal details. Next section comprises of five questions related to the participant's personal experiences with antibiotic use, (closed ended questions). The coming sections consist of 2 questions (closed ended) related to antibiotics usage in animals, and the next has eight questions (5 closed ended and 3 open ended questions) related to antibiotics use, experiences and behavioral practices. Last section consists of four questions (3 closed ended and 1 open ended) related to public awareness and interaction with healthcare providers.
3.8 METHODOLOGY
The study employed a qualitative approach, using structured interviews to collect data from participants in urban and rural areas. The interviews focused on participants' antibiotic usage patterns, sources of procurement, disposal methods, awareness of antibiotic resistance, and reasons for discontinuing antibiotic courses prematurely. The data were analyzed to identify trends and differences between urban and rural populations.
3.9 Data Analysis
The response to the questionnaire was analyzed by performing descriptive statistics using graphical representations.
The sample size of 260 was calculated based on the formula for estimating sample sizes in cross-sectional surveys, considering a predicted proportion (p) of 0.39 (39% of people knew about the proper usage of antibiotics). Using a confidence level of 95% (Z1-α/2 = 1.96) and an absolute precision (d) of 5%, the formula determined the minimum required sample size to be 366. However, the study's sample size of 260 was derived due to practical constraints or adjustments in the methodology. This sample size ensures sufficient power to detect meaningful trends or differences in antibiotic knowledge and attitudes among the general public in the region.
RESULT AND DISCUSSION
The study provides a comparative analysis of antibiotic use and resistance patterns among urban (48.3%) and rural (51.7%) populations in Fig. 1. The findings reveal both similarities and significant differences in antibiotic practices between these two groups, highlighting the need for targeted interventions to address the misuse of antibiotics and the growing threat of antibiotic resistance. Antibiotic resistance occurs when bacteria evolve mechanisms to survive the effects of antibiotics, often due to genetic mutations or resistance genes. This process is accelerated by the overuse or misuse of antibiotics, such as in treating viral infections, incomplete treatment courses, or agricultural overuse. Such practices create selective pressure, enabling resistant strains to thrive and leading to the emergence of "superbugs" that are hard or impossible to treat. The consequences include prolonged illnesses, higher healthcare costs, increased mortality, and untreatable infections. Combating this crisis requires responsible antibiotic use, better infection prevention, and the development of new treatments and therapies.
Fig. 1 Urban and Rural Population Distribution.
The irrational use of antibiotics stems from a combination of factors, such as limited awareness, cultural misunderstandings, and economic pressures. In numerous developing nations, antibiotics are frequently sold over the counter without prescriptions, primarily due to high consumer demand and weak regulatory enforcement. To tackle these issues, it is essential to implement educational initiatives and strengthen the enforcement of existing policies. Additionally, addressing systemic challenges like healthcare infrastructure gaps, profit-driven practices by pharmacies, and the lack of access to affordable diagnostic tools can further mitigate the misuse of antibiotics. Collaborative efforts involving governments, healthcare providers, and communities are vital to promoting responsible antibiotic use and combating the growing threat of antimicrobial resistance.
4.1 RESULT
The study provides a comprehensive overview of antibiotic use patterns, highlighting both adherence to formal healthcare systems and concerning practices that contribute to antibiotic misuse and resistance.
Fig. 2 Population Distribution by Age Group.
Fig. 2 provides a breakdown of the age distribution among participants, categorized into four groups: 18-25, 25-35, 35-45, and 45-55. The majority of respondents (46.9%) fall within the 18-25 age group, indicating that this demographic is the most represented in the study. The 45-55 age group follows with 23.5%, while the 25-35 and 35-45 age groups account for 16.2% and 13.5% of the participants, respectively. This distribution suggests that the study primarily reflects the perspectives and experiences of younger adults, particularly those aged 18-25. These findings highlight the importance of considering age-related factors when interpreting the results and designing future research to ensure a more comprehensive understanding across all age groups.
Fig. 3 Antibiotic use without a prescription.
Fig. 3.1 Antibiotic Use Without A Prescription.
Fig. 3 illustrates responses to the question, "Have you ever taken an antibiotic without a prescription?" with 80.4% of participants answering "No" and 19.6% responding "Yes." This indicates that a significant majority of respondents taken antibiotics without a prescription in rural area compared to urban area, highlighting a concerning trend of self-medication in rural area. The low percentage of "Yes" responses suggests a potential lack of awareness or disregard for the risks associated with unprescribed antibiotic use, such as antibiotic resistance and adverse health effects. Fig 3.1 Indicates that the majority of those who answered “Yes” were from rural areas, while most of those who answered no were from urban areas. Educating people on the correct use of V antibiotics and encouraging them to consult a doctor before taking medication is essential. Promoting responsible antibiotic use is crucial in preventing antibiotic resistance, which is a growing health concern. This finding underscores the need for increased public education on the proper use of antibiotics, especially in rural areas, where awareness is lower compared to urban areas. It highlights the importance of consulting healthcare professionals before taking such medications. Addressing this issue is crucial for promoting responsible antibiotic use and mitigating the growing challenge of antibiotic resistance.
Fig. 4 shows the sources from which participants obtain antibiotics, with 41.9% reporting that they acquire them from hospitals, 54.2% from medical stores, and a smaller proportion from other unspecified sources. The data indicates that medical stores are the most common source of antibiotics for the majority of respondents, surpassing hospitals by a significant margin. However, rural participants were more likely to obtain antibiotics without a prescription compared to their urban counterparts. This is evident from the higher percentage of rural respondents reporting the use of medical stores and other informal sources for antibiotic access. A significant proportion of rural participants (Fig. 4.1) admitted purchasing antibiotics over the counter, reflecting weaker regulatory enforcement and limited access to healthcare facilities in rural areas. This suggests a prevalent trend of purchasing antibiotics directly from pharmacies without necessarily obtaining a prescription from a healthcare provider. The reliance on medical stores highlights potential gaps in regulatory oversight and the need for stricter enforcement of prescription requirements to curb the misuse of antibiotics. Additionally, the presence of "other sources" indicates that some respondents may be obtaining antibiotics through informal or unregulated channels, further emphasizing the importance of public awareness campaigns and policy interventions to promote responsible antibiotic use and reduce the risk of antibiotic resistance. The responses to the question, "Have you used antibiotics without a prescription recently? If not, what prevented you from doing so?" reveal a range of reasons why individuals may avoid self-medicating with antibiotics. A significant number of respondents indicated that they did not use antibiotics without a prescription due to awareness of the potential side effects and risks associated with improper use. This suggests that educational efforts and awareness campaigns about the dangers of antibiotic misuse have had a positive impact, particularly in urban areas where awareness appears to be comparatively higher. Several respondents explicitly mentioned their knowledge and understanding of the side effects of antibiotics as a deterrent, highlighting the importance of informed decision-making. Others stated that they only take medication when it is necessary and prescribed by a healthcare professional, reflecting a responsible approach to medication use. However, a few respondents admitted using antibiotics without a prescription, indicating that there is still a need for continued education and stricter enforcement of regulations in rural areas regarding antibiotic access. Overall, these findings underscore the effectiveness of awareness campaigns in promoting responsible antibiotic use. They also highlight the ongoing need for education to reach those who may still be unaware of the risks associated with self-medication. Ensuring that accurate information is widely available and accessible which can help further reduce the misuse of antibiotics and contribute to the global effort to combat antibiotic resistance.
Response to the question, "Do you stop taking antibiotics before you finish the course as directed?"(Fig 3) reveal a nearly equal split, with 50.8% of participants answering "Yes" and 49.2% responding "No." This indicates that a significant portion of respondents do not complete their prescribed antibiotic courses, which is a concerning trend. need for targeted interventions to improve adherence to prescribed treatment in these regions. The study found that 50.8% of participants discontinued their antibiotic courses prematurely (Fig. 5). This trend was more pronounced in rural areas, where participants often stopped taking antibiotics once they felt better or due to side effects such as gastric issues, allergies, or headaches. Urban participants, while also reporting premature discontinuation, were slightly more likely to complete their courses, possibly due to better access to healthcare advice and awareness. The close division between "Yes" and "No" responses highlights the need for targeted educational interventions to emphasize the critical role of adhering to prescribed antibiotic regimens. Addressing this issue is essential for improving public health outcomes and combating the growing challenge of antibiotic resistance.
Responses to the question, "Have you ever experienced a serious, life- threatening situation as a result of antibiotic use during hospital or while receiving treatment at home?"(Fig 6) show that 91.9% of participants answered "No," while only 8.1% responded "Yes." This overwhelming majority indicates that a significant number of respondents in rural areas have encountered severe adverse effects from antibiotic use, highlighting the greater potential risks in these regions compared to urban areas. The low percentage of "Yes" responses underscores the importance of careful monitoring and management of antibiotic treatments, both in hospital settings and at home. It also suggests a need for improved patient education on the potential side effects of antibiotics and the importance of reporting adverse reactions to healthcare providers promptly. These findings emphasize the critical need for healthcare systems to prioritize patient safety and implement strategies to mitigate the risks associated with antibiotic therapy.
Illustrates responses to the question, "Have you ever experienced an allergic reaction to an antibiotic?"(Fig.7) reveal that 9.2% of participants answered "Yes," while 90.8% responded "No." Notably, the 9.2% who reported allergic reactions were primarily from rural areas, indicating a higher prevalence of such reactions in these regions compared to urban areas. This indicates that a small but notable proportion of respondents have experienced allergic reactions to antibiotics, although majority have not encountered such reactions. Allergic reactions to antibiotics can range from mild to severe and potentially life-threatening, underscoring the need for healthcare providers to thoroughly assess patients' medical histories and monitor for adverse effects during treatment. These findings suggest that while antibiotic allergies are relatively uncommon, they remain a significant concern that warrants attention to ensure patient safety and effective treatment outcomes.
Fig. 8 Prevalence of Human Antibiotic Use in Domestic Animals
Responses to the question, "Do you use human antibiotics in pets/domestic animals?" (Fig 8) show that 94.2% of participants answered "No," while 5.8% responded "Yes." This indicates that the vast majority of respondents do not use human antibiotics for their pets or domestic animals, reflecting a general awareness of the potential risks and differences in medication requirements between humans and animals. However, a small percentage (5.8%) from rural areas who do use human antibiotics for animals highlights a practice that could contribute to antibiotic resistance and pose health risks to both animals and humans. This finding underscores the importance of educating pet owners about the appropriate use of veterinary-prescribed antibiotics and the dangers of cross- species medication use. Urban areas, with better access to veterinary facilities, showed more responsible practices. Addressing this issue is crucial for promoting responsible antibiotic use and mitigating the broader public health challenge of antibiotic resistance. The responses to the question, "If you have not finished your prescribed antibiotic in the past, what was the reason?" reveal a variety of reasons why individuals may not complete their antibiotic courses. The most common reason cited is feeling better or the illness being cured, with many respondents indicating they stopped taking antibiotics once they felt improved. This suggests a widespread misconception that antibiotics can be discontinued once symptoms subside, rather than completing the full course as prescribed. Notably, this issue is more prevalent in rural areas, where a lack of awareness and limited access to healthcare resources contribute to improper antibiotic use. Other significant reasons include forgetting to take the medication, experiencing side effects such as gastric issues, diarrhoea, headaches, or allergic reactions, and difficulties in swallowing or tolerating the medication. These challenges are often exacerbated in rural regions due to lower healthcare literacy and fewer medical facilities for consultation. Some respondents also mentioned stopping antibiotics due to a lack of interest or awareness about the importance of completing the course. These findings highlight critical gaps in patient education and understanding regarding the proper use of antibiotics, particularly in rural areas. The tendency to stop antibiotics prematurely, especially after symptoms improve, can contribute to antibiotic resistance and treatment failure. The reported side effects and difficulties in taking the medication also underscore the need for healthcare providers to address patient concerns and provide support to ensure adherence to prescribed treatments. Addressing these issues through targeted educational campaigns, better patient-provider communication, and strategies to manage side effects is essential for improving antibiotic adherence and combating the growing challenge of antibiotic resistance.
Improper disposal of antibiotics was more prevalent in rural areas Fig. 9 shows that 41.9% of participants dispose of antibiotics in garbage, 25.8% soil, 22.3% incinerate them, and 10% dispose of them with water. Urban participants were more likely to use safer disposal methods, such as incineration or returning antibiotics to pharmacies, though improper disposal was still a concern. Fig 9.1 indicates, not only a lack of proper disposal methods but also a significant lack of awareness among the rural population regarding the environmental and health risks associated with improper antibiotic disposal. The widespread practice of discarding antibiotics in open environments can contribute to environmental contamination and the spread of antibiotic resistance. Addressing this issue through targeted awareness campaigns and improved disposal facilities in rural areas is essential to mitigate these risks and promote safer disposal practices.
Awareness of antibiotic resistance was higher among urban participants (Fig. 10), with 37.3% of respondents having heard of the term "antibiotic resistance," while 62.7% had not. Many cited newspapers, healthcare providers, and the internet as their primary sources of information. In contrast, rural participants demonstrated lower awareness levels, often relying on informal sources such as friends and family for information about antibiotics. Despite this awareness, a small proportion of urban participants still engaged in self-medication and the use of antibiotics without prescriptions, indicating that awareness alone is insufficient to prevent misuse. This highlights the need for increased education and awareness campaigns, as a significant portion of the population remains unaware of this critical public health issue.
12.7% of participants reported using leftover antibiotics or sharing them with others, while only 87.3% did not (Fig 11). This low percentage highlights a widespread but risky practice that can lead to inappropriate antibiotic use, contributing to resistance and potential health risks. The histogram (fig 11.1) shows the percentage of rural and urban participants who use or share leftover antibiotics. Antibiotic abuse is more prevalent in rural areas due to lack of awareness and limited healthcare access, highlighting the need for improved instruction on proper antibiotic use. Rural participants were more likely to share leftover antibiotics or use them without a proper diagnosis, as shown (Fig. 11) and (Fig. 12). In contrast, this practice was less common in urban areas, where participants tended to rely on previous prescriptions or healthcare advice. Additionally, approximately 10% of participants, particularly in rural areas, reported that antibiotics were ineffective for them, which could indicate early signs of resistance development. Regarding self-medication based on previous prescriptions, Fig. 12 shows that 25.4% of respondents take antibiotics based on prior prescriptions or experiences, while 74.6% do not. This suggests a prevalent trend of self-medication, which can result in incorrect dosages and durations, further exacerbating the issue of antibiotic resistance. The responses to the question, "Have you ever experienced no effect while taking an antibiotic, whether it be at home or in a hospital? If yes, do you have more information regarding the incident?" The data shows that 78.5% of respondents answered "Yes”, indicating that a significant majority have experienced situations where antibiotics were ineffective. Among these, 21.5% provided additional information, mentioning issues such as diarrhoea, the antibiotic not curing the condition, difficulties in treatment, and increased symptoms. This high percentage of "Yes" responses highlights a concerning trend of antibiotic ineffectiveness, which could be attributed to factors such as antibiotic resistance, incorrect diagnosis, or inappropriate use of antibiotics. The additional information provided by some respondents underscores the varied and sometimes severe consequences of antibiotic ineffectiveness, including prolonged illness and complications. These findings emphasize the critical need for proper diagnosis, appropriate antibiotic prescribing practices, and patient education on the correct use of antibiotics. Addressing these issues is essential for improving treatment outcomes and combating the growing challenge of antibiotic resistance. Further research into the specific causes of antibiotic ineffectiveness and targeted interventions could help mitigate these problems and enhance public health.
81.2% of participants reported not feeling pressure from family or friends to take antibiotics for conditions that may not require them, while 18.8% did (Fig. 13). Notably, this pressure was more prevalent among rural participants, where cultural beliefs and limited healthcare awareness often lead to inappropriate antibiotic use. In contrast, urban participants experienced less social pressure, likely due to better access to medical guidance and greater awareness of antibiotic risks. This misuse is further compounded by a lack of public awareness, as shown (Fig. 14), where 85.4% of respondents believe there is insufficient understanding about the risks of antibiotic misuse and resistance in their communities, while only 14.6% think awareness is adequate. The lack of knowledge was particularly pronounced in rural areas, where many individuals were unaware that misuse could lead to antibiotic resistance, unlike urban participants who generally had better awareness. The responses to the question, "Where do you typically get information about antibiotics?" reveal a diverse range of sources that individuals rely on for information. The most frequently mentioned sources include hospitals, doctors, and healthcare providers, indicating that professional medical advice remains a primary and trusted source of information. Additionally, the internet, including platforms like Google and YouTube, is a significant source, reflecting the growing reliance on digital resources for health-related information. Social media, newspapers, and television also play a role in disseminating information about antibiotics, highlighting the influence of mass media and online platforms. Friends and family are mentioned as sources, suggesting that personal networks contribute to individuals understanding of antibiotic use. However, some respondents mentioned awareness classes, journals, and medical websites, indicating that more formal and educational channels are also utilized, though perhaps less frequently. A few responses pointed to previous experiences and professional knowledge, which may indicate a reliance on personal or professional background for information. The variety of sources underscores the importance of ensuring that accurate and reliable information about antibiotics is widely available across different platforms. It also highlights the need for healthcare providers to actively educate patients and for public health campaigns to leverage multiple media channels to reach a broader audience. Addressing misinformation and promoting best practices in antibiotic use through these diverse channels is crucial for improving public health outcomes and combating antibiotic resistance.
61.5% of participants reported being advised by a healthcare provider to stop taking antibiotics or avoid unnecessary use, while 38.5% had not received such guidance (Fig 15). This suggests that healthcare providers may not consistently communicate the importance of prudent antibiotic use, which is critical for combating resistance. Additionally, healthcare professionals advise both urban and rural populations on the use of antibiotics. However, compared to rural populations, urban populations are relatively more likely to receive counselling, suggesting a possible communication and accessibility gap in healthcare in rural areas. This discrepancy emphasizes the necessity of focused awareness campaigns to guarantee that people in every area receive sufficient instruction on how to use antibiotics responsibly.
Similarly, Fig. 16 reveals that 43.8% of respondents recalled their doctor performing a test before prescribing antibiotics, whereas 56.2% did not, indicating that diagnostic testing is not universally practiced. This inconsistency can lead to inappropriate antibiotic prescriptions and misuse. The percentage of people in both rural and urban areas who had tests performed prior to receiving an antibiotic prescription is shown (Fig 16.1). According to the data, both populations underwent a sufficient number of tests prior to being prescribed antibiotics. However, compared to urban areas, a smaller percentage of people in rural areas are tested. This implies that even though testing is taking place in both areas, there might be some restrictions in rural areas due to things like accessibility to medical facilities, availability of diagnostic services, or variations in medical procedures. By addressing these differences, both rural and urban populations may benefit from more uniform and fair antibiotic stewardship. These findings, combined with earlier insights into social pressures and gaps in public awareness, highlight significant challenges in addressing antibiotic resistance. Social influences, inadequate healthcare communication, and inconsistent diagnostic practices collectively contribute to the misuse of antibiotics. To tackle this growing public health threat, targeted education campaigns, improved healthcare practices, and stronger community engagement are essential. By addressing these gaps, we can promote responsible antibiotic use and mitigate the risks of resistance.
1.1DISCUSSION
The findings of this study reveal significant differences and similarities in antibiotic use and resistance patterns between urban and rural populations. While both groups rely on formal healthcare systems for antibiotic procurement, rural populations are more likely to engage in practices such as sharing antibiotics, self-medication, and improper disposal. These differences can be attributed to factors such as limited access to healthcare facilities, lower awareness levels, and weaker enforcement of regulations in rural areas. This aligns with previous studies that have highlighted the disparities in healthcare access and education between urban and rural settings (Author et al., Year). The study underscores the critical role of awareness in shaping antibiotic use practices, as participants who were aware of antibiotic resistance were less likely to misuse antibiotics. However, the persistence of misuse even among aware individuals suggests that awareness alone is insufficient, and more targeted interventions are needed, particularly in rural areas, to address knowledge gaps and misconceptions. The availability of antibiotics without prescriptions, especially in rural areas, highlights the need for stricter enforcement of regulations. Policies aimed at curbing over-the- counter sales and promoting responsible antibiotic use are essential to mitigate misuse. The practice of discontinuing antibiotics prematurely or sharing them with others further underscores the need for behavioral change interventions. Public health campaigns should emphasize the importance of completing antibiotic courses and the dangers of self-medication. These campaigns must be tailored to address the specific needs and challenges of different populations, particularly in rural areas where access to healthcare and information is often limited. This finding is consistent with global efforts to combat antibiotic resistance, which emphasize the importance of education and regulation in reducing inappropriate antibiotic use. Improper disposal of antibiotics poses significant environmental and public health risks, as antibiotics can leach into soil and water systems, contributing to the development of resistant bacteria in the environment. Educational programs should include guidance on safe disposal methods, such as incineration or returning unused antibiotics to pharmacies. These programs must be widely disseminated and accessible to all segments of the population, with a particular focus on rural areas where improper disposal practices are more prevalent. Improving access to healthcare services, particularly in rural areas, can reduce reliance on self-medication and informal antibiotic sharing. Innovative solutions such as telemedicine and mobile health clinics could bridge the gap in healthcare access and provide much-needed medical supervision and guidance. Urban participants demonstrated a higher level of awareness regarding antibiotic resistance and the importance of completing antibiotic courses. This awareness, coupled with better access to healthcare facilities, contributed to more responsible antibiotic use. However, the persistence of self-medication and improper disposal practices in urban areas indicates that there is still room for improvement. Public health campaigns in urban areas should focus on reinforcing the importance of proper antibiotic use and disposal, leveraging digital platforms and media to reach a wider audience. This is particularly relevant given the increasing reliance on digital resources for health-related information in urban settings. In rural areas, participants faced greater challenges, including limited access to healthcare facilities, lower awareness levels, and weaker enforcement of regulations. These factors contributed to higher rates of self-medication, improper disposal, and the use of antibiotics for veterinary purposes. Addressing these issues requires intensified awareness programs tailored to rural populations, utilizing local media, community health workers, and village-level workshops to disseminate information about the dangers of antibiotic misuse and resistance. Stricter enforcement of regulations is also needed to curb over-the-counter sales of antibiotics and ensure that antibiotics are only dispensed with a valid prescription. Additionally, improving access to healthcare services in rural areas through telemedicine, mobile health clinics, and the establishment of more healthcare facilities would reduce reliance on self-medication and informal antibiotic sharing. Both urban and rural populations exhibited concerning practices such as premature discontinuation of antibiotics and improper disposal. These practices contribute to the development of antibiotic resistance and pose significant public health risks. However, due to factors like inconsistent adherence to prescribed antibiotic regimens, lower awareness levels, and limited healthcare access, the rural population seems to be more vulnerable to antibiotic resistance. To lessen the growing threat of antibiotic resistance in rural communities, these issues must be addressed through focused educational initiatives and enhanced healthcare facilities. Educational programs should emphasize the importance of completing antibiotic courses and provide clear guidelines on safe disposal methods, such as returning unused antibiotics to pharmacies or using incineration facilities. The improper disposal of antibiotics, particularly in rural areas, poses significant environmental risks, as antibiotics can leach into soil and water systems, contributing to the development of resistant bacteria in the environment. Addressing this issue requires widespread dissemination of information on safe disposal practices and the establishment of accessible disposal facilities.
In conclusion, the findings of this study highlight the disparities in knowledge and healthcare access between rural and urban populations regarding antibiotic resistance. The rural population is more susceptible to inappropriate antibiotic use and the emergence of antibiotic resistance because they are less aware of the negative effects of antibiotic misuse. In order to encourage the responsible use of antibiotics, it is imperative that healthcare access and educational programs in rural areas be improved. On the other hand, people in cities tend to know more about antibiotic resistance, probably because they are more exposed to medical facilities and public health initiatives. Targeted awareness campaigns, better healthcare facilities, and more stringent regulations—especially in rural areas—should be put in place to close this gap. By stepping up these efforts, we can make sure that antibiotics continue to be available and effective for people who really need them. These results add to the expanding corpus of research on antibiotic resistance and provide useful information for public health professionals, legislators, and healthcare professionals.
5. SUMMARY AND CONCLUSION
Antibiotic resistance has emerged as a critical global public health challenge, threatening the efficacy of antibiotics and posing significant risks to the treatment of infections. This study aimed to compare antibiotic use patterns and resistance prevalence between urban and rural populations in Kerala, India, to identify the root causes of misuse and resistance. Using a cross-sectional observational design, the study surveyed 258 individuals aged 18-55 who had used antibiotics in the past six months. Data were collected through structured interviews and questionnaires, focusing on antibiotic procurement, usage, disposal practices, awareness of antibiotic resistance, and adherence to prescribed courses. The findings revealed that while both urban and rural populations primarily obtained antibiotics through formal healthcare systems, rural populations exhibited higher rates of self-medication, antibiotic sharing, and improper disposal. Urban participants demonstrated greater awareness of antibiotic resistance, but both groups displayed significant knowledge gaps, particularly regarding the importance of completing antibiotic courses and safe disposal methods. The study also highlighted the misuse of human antibiotics in animals and the environmental risks posed by improper antibiotic disposal, both of which contribute to the growing problem of antimicrobial resistance. Key factors influencing antibiotic misuse included limited access to healthcare, economic constraints, cultural practices, and weak regulatory enforcement. The study identified a concerning trend of premature discontinuation of antibiotic courses, often due to perceived recovery or side effects, as well as the sharing of leftover antibiotics without proper diagnosis. These practices, coupled with the improper disposal of antibiotics, exacerbate the development of resistant bacterial strains. The study underscores the urgent need for targeted interventions to address these issues. Public awareness campaigns, particularly in rural areas, are essential to improve knowledge about antibiotic resistance and promote responsible use. Stricter enforcement of regulations is necessary to curb over-the-counter sales and ensure that antibiotics are dispensed only with valid prescriptions. Educational programs should emphasize the importance of completing antibiotic courses and provide guidance on safe disposal methods, such as incineration or returning unused antibiotics to pharmacies. Additionally, improving access to healthcare services in rural areas can reduce reliance on self-medication and informal antibiotic sharing. Innovative solutions, such as telemedicine and mobile health clinics, could help bridge the gap in healthcare access. The study also calls for stricter regulations on the use of antibiotics in animal agriculture to prevent the transfer of resistant bacteria to humans through the food chain or environmental contamination. In conclusion, this study highlights the complex interplay of behavioral, socioeconomic, and systemic factors that contribute to antibiotic misuse and resistance in urban and rural populations. Addressing these challenges requires a multifaceted approach, combining public education, regulatory enforcement, improved healthcare access, and environmental safeguards. By implementing these measures, it is possible to mitigate the emergence of resistant bacterial strains, preserve the efficacy of antibiotics, and safeguard public health for future generations. The findings emphasize the importance of context-specific strategies to combat antibiotic resistance, tailored to the unique needs and challenges of different demographic settings.
Review Of Literature
1.D. G. Joakim Larsson, et. al, (2021) performed a study on ‘Antibiotic resistance in the environment’. A worldwide health concern, antibiotic resistance is caused by the spread of bacteria and genes from people to animals and the environment. Our capacity to prevent and treat illnesses is diminished when pathogens develop new resistance factors. For crisis management, it is essential to comprehend how the environment affects resistance evolution, transmission, and risk scenarios. In addition to identifying steps to reduce risks, this review provides up-to-date evidence, risk scenarios, surveillance techniques, and potential drivers.
2.Abbye W. Clark, et. al, (2021) did a study about ‘Rural–urban differences in antibiotic prescribing for uncomplicated urinary tract infection’. In contrast to urban women, a considerable percentage of rural-urban women with uncomplicated UTIs received inappropriate agents (46.7%) or durations (76.1%), according to a study comparing antibiotic use among these women. Prescriptions with excessively long durations were more likely to be given to rural women. According to the study, antimicrobial stewardship initiatives are required to enhance the prescription of antibiotics for UTIs in outpatient settings and minimize needless antibiotic exposure, particularly in rural areas. The results emphasize the necessity of successful antimicrobial stewardship initiatives.
3. Balachandra, et. al, (2021) conducted study about ‘Antimicrobial resistance (AMR) at the community level an urban and rural case study from Karnataka’. Antimicrobial resistance in India costs the world economy $100 trillion and causes 700,000 deaths annually. The Indian Council of Medical Research launched the National Programme on Antimicrobial Surveillance to address this issue, emphasizing local patterns and interdisciplinary collaboration. The high prevalence of AMR in both rural and urban areas is revealed by the study, highlighting the necessity of local data and establishing connections between hospitals, primary health centers, and rural practices for efficient antibiotic stewardship.
4.Patrick Oliver Asogwa, et. al, (2023) performed a study ‘Observational Studies of Prescription Pattern and Use of Antibiotics in Selected Rural Areas’. Antibiotic misuse, including overuse and inappropriate use, threatens public health by accelerating antibiotic resistance. The WHO's Aware antibiotic classification framework helps optimize use. This study examines prescription patterns in India, suggesting improved prescription practices and public education on appropriate antibiotic use.
5.Kieran Osbiston, et. al, (2020) did a study about ‘Antibiotic resistance levels in soils from urban and rural land uses in Great Britain’. Although soil is a major repository of microbial diversity, little is known about how it works. Antibiotic resistance levels in soils from semi-natural, urban, and agricultural land uses were investigated in a British study. ARB levels on agricultural land differed significantly from those in urban or semi-natural areas, according to statistical analysis. While resistance to subinhibitory erythromycin concentrations was less significant in agricultural soil than in urban or semi-natural soil, resistance to vancomycin and chloramphenicol was stronger in both urban and agricultural sites.
6.Giuseppe Mancuso, et. al, (2021) performed a study ‘Bacterial Antibiotic Resistance: The Most Critical Pathogens’. Although antibiotics have been used to treat bacterial diseases such as bacteremia and meningitis, their abuse and overuse have caused antibiotic-resistant bacteria to proliferate. Without new therapies, the World Health Organization estimates that this number might increase to 10 million by 2050. The highest priority classification has been assigned to the ESKAPE diseases, which pose the most harm to humans. It is essential to comprehend these resistance processes in order to create novel antimicrobial medications.
7.Nicholas A. Church, et. al, (2021) conducted a study ‘Antibiotic resistance crisis: challenges and imperatives.’ Over 700,000 people die each year from diseases brought on by bacteria resistant to antibiotics, making antibiotic resistance a serious worldwide concern. The most frequent source of hospital-acquired illnesses is the ESKAPE group of bacteria, which can withstand strong medications. In order to solve this quiet global catastrophe, substantial changes in healthcare and consumer behavior are required, yet little research is focused on creating new substances to fight resistance.
8.Md. Jamal Hossain, et. al, (2023) did a study ‘Irrational use of antibiotics and factors associated with antibiotic resistance: Findings from a cross-sectional study in Bangladesh’. The purpose of this study was to evaluate the usage patterns of antibiotics (AB) and factors linked to irrational use that are linked to antibiotic resistance (ABR) among instructors and students at a top public institution in Bangladesh. According to the results of a cross-sectional web-based poll, men respondents reported a 34% worse experience obtaining ABR than female respondents. In comparison to master's or upper-class students, first- and second-year students had more ABR experience. ABR was 57% less likely to occur in participants who finished their AB prescription.
9.Abubakar Siddique, et. al, (2020) did a study about ‘Evaluation of Rational use of Antibiotics in Medicine Ward of a Tertiary Care Hospital’. This study assessed the antibiotic prescribing practices in the medicine ward of a Bangalore tertiary care hospital. Following Quinolone (19.6%), Cephalosporins + Penicillinase Inhibitors (13.15%), Penicillin + Penicillinase Inhibitors 73 (6.03), Aminoglycoside (2.23%), Macrolides (1.07%), Sulphonamides (0.08%), Tetracyclines (0.16%), and others (10.1%), Cephalosporins (47.22%) were the most often prescribed class. The results emphasize how crucial it is to comprehend antibiotic prescription trends in order to implement sensible usage and successful treatment strategies.
10. Aisha Tanvee, et. al, (2022) did a study about ‘Assessment of Community Pharmacists’ Knowledge, Attitude and Practice on Antibiotics and Antibiotic Resistance’. A study in Hyderabad found that 78% of community pharmacists had no knowledge about antibiotic resistance, indicating inadequate knowledge and poor dispensing procedures. Most pharmacists prescribe antibiotics without a prescription, with patient requests being the most common justification. To improve understanding and practice, strict regulations, educational materials, short-term training programs, and frequent inspections are needed. The results can inform educational initiatives to raise pharmacist awareness, but may introduce bias due to the self-administered questionnaire.
11.Hayat A Al-Btoush, et. al, (2023) conducted a study about ‘Assessment of knowledge, behaviour and awareness towards antibiotic use and resistance: a cross-sectional study from south Jordanian society’. The study assesses southern Jordanian citizens' awareness of antibiotic use and resistance. According to a cross-sectional survey, 53% of participants showed unfavorable behavior about the usage of antibiotics; middle school students, non-medical field workers, and non-employees had the greatest percentages. 48.0% of respondents, especially those aged 17 to 27, demonstrated a high level of knowledge and awareness of antibiotic resistance. Antibiotic resistance is largely caused by doctors and pharmacists, which emphasizes the necessity of regulatory measures to restrict antibiotic access and overuse.
12. Nirmal K. Ganguly, et. al, (2021) did a study about ‘Rationalizing antibiotic use to limit antibiotic resistance in India’. Globally, antibiotic resistance is a problem, particularly in developing countries like India. To address this issue, the Global Antibiotic Resistance Partnership (GARP) created policy recommendations. According to the report, antibiotic use for agricultural growth promotion must be curbed, resistance-enhancing drug pressure must be decreased, and antibiotic use must be eliminated. Important steps include strengthening infection control committees, expanding diagnostic testing, prioritizing national surveillance, and limiting the use of antibiotics for purposes other than therapeutics. Vaccinating more children could also save antibiotics and lessen the burden of disease.
13.Khyati Bhardwaj, et. al, (2021) performed a study about ‘Knowledge, attitude, and practices related to antibiotic use and resistance among the general public of coastal south Karnataka, India – A cross-sectional survey’ the study aimed to understanding community attitudes and behaviors around antibiotic usage and resistance was the goal of the study. 515 participants in the Dakshina Kannada District provided the data. The findings revealed a poor response rate, with 52% of respondents having false information on antibiotic resistance and 49% not knowing how antibiotics work. 45% of respondents used prescription antibiotics for colds, and the majority had a positive attitude about them. Public education about responsible antibiotic usage should be the main focus of future efforts. From the pilot study 39% was found to be the predicted percentage of those who knew about the usage of antibiotics. Using the formula n = Z21-α/2p(1-p)/d2, where p is the predicted proportion (0.39), Z1-α/2 is the alpha error 1.96 (the confidence interval 95%), and d is the absolute precision (5%), the study's minimal sample size was determined to be 366.
14.Nguyen NV, et. al, (2022) conducted a study about ‘Knowledge, Attitude, and Practice Regarding Antibiotic Use and Resistance for Upper Respiratory Tract Infections among the Population Attending a Mass Gathering in Central India: A Cross-Sectional Study’ An investigation into the general public's knowledge, attitude, and behavior (KAP) about antibiotic use, upper respiratory tract infection (URTI) resistance, and related factors was carried out in India. In 2016, a cross-sectional study was carried out at a large event in the city of Ujjain. According to the findings, 93% of participants misdefined antibiotics, and 89.9% of participants knew very little about URTIs. The majority of participants were unable to name factors that contribute to the irrational use of antibiotics. While 87% of subjects denied taking antibiotics as directed, 40% of people showed appropriate attitudes. According to the study's findings, community interventions—like educational campaigns—should be planned and carried out as soon as possible while taking demographic variations into account.
15.Chokshi, et. al, (2019) conducted a study about ‘Global Contributors to Antibiotic Resistance’. The rise in antibiotic-resistant illnesses around the world emphasizes the necessity of a thorough grasp of the political and socioeconomic elements influencing this problem. Key factors in underdeveloped nations were found by a previous study, including clinical overuse, low-quality antibiotics, easy availability, and a lack of surveillance. Antibiotic resistance in wealthy nations is a result of inadequate hospital-level regulation, overuse of antibiotics in animals raised for food, and a lack of financial incentives for new antibiotic research.
16.Maya L. Nadimpalli, et. al, (2020) did a study about ‘Urban informal settlements as hotspots of antimicrobial resistance and the need to curb environmental transmission’. Globally, antibiotic-resistant illnesses are increasing, underscoring the necessity of a thorough comprehension of socioeconomic and political causes. Lack of surveillance, low-quality antibiotics, clinical misuse, and accessibility are major factors in developing nations, whereas inadequate hospital regulation, overuse of antibiotics in animals raised for food, and a lack of financial incentives are major factors in developed nations. The report emphasizes how difficult it is to upgrade the water and sanitation systems in urban informal settlements, particularly in areas where there is a serious AMR (antimicrobial resistance) crisis. It highlights the necessity of long-term strategies to stop the spread of environmental AMR and enteric pathogens. The study identifies research directions to enhance community-wide water, waste, and drainage infrastructure, with a focus on urban informal settlements as a major hotspot, given that millions of urban residents are anticipated in LMICs (Lower- and middle-income countries).
17.Indira K.S, et. al, (2008) conducted a study on ‘Antimicrobial prescription patterns for common acute infections in some rural & urban health facilities of India’. In both rural and urban India, the study examined the prevalence and trends of antimicrobial prescriptions for patients with fever, diarrhea, and uncomplicated acute respiratory infections. There was significant variation in the overall antimicrobial prescription rate of 69.4%. Antimicrobial prescriptions were more common in rural and public/government settings than in urban and private ones. High-income patients received more antimicrobials, and the highest rate was seen in children aged 6 to 18. Quinolones and cephalosporins were more frequently prescribed, but penicillin’s and co-trimoxazole accounted for two-thirds of all prescriptions.
18. Nowakiewicz, et. al, (2020) performed a study on ‘Last Call for Replacement of Antimicrobials in Animal Production: Modern Challenges, Opportunities, and Potential Solutions’. Antibiotics must be used in animal production due to the growing demand for food derived from animals. Drug resistance data, however, points to a possible reversion to the preantibiotic period. Alternatives to antibiotics are deemed necessary, but implementation challenges and market analyses do not guarantee their complete replacement. This publication provides an overview of drug resistance, steps taken to address it, and two alternatives that are most comparable to antibiotics.
19.Chandra, et. al, (2020) conducted a study on ‘Antimicrobial resistance Call for rational antibiotics practice in India’ The scientific community is becoming increasingly concerned about antimicrobial resistance (AMR), which affects both antibiotics and the microorganisms that produce them. Antibiotics, the causes of AMR, and their impacts in both Indian and global contexts are the main topics of this review article. It advances human knowledge and helps create new antibiotics. A thorough statistical analysis is required due to the growing number of resistant microbes in both Indian and global contexts.
20.Chen, et. al, (2023) conducted a study on ‘Environmental determinants and demographic influences on global urban microbiomes, antimicrobial resistance and pathogenicity’ The Meta Sub Consortium conducted a comprehensive global survey of urban microbiomes, examining their impact on global diversity and composition. The study found that PM10 concentration positively influenced microbial diversity, while GDP per capita negatively impacted it. Environmental characteristics such as Köppen climate type, vegetation type, greenness fraction, soil type, PM2.5 concentration, annual average precipitation, and temperature shaped β-diversity. Cities with higher precipitation and greenness fractions had higher microbial species. The study suggests that managing air quality and urban greenness is crucial for regulating urban microbial diversity, while socio-economic factors, particularly reducing antibiotic usage in regions with lower GDP, are crucial for curbing antimicrobial resistance.
21.Tanya Verma, et. al, (2022) performed a study on ‘Current challenges and advancements towards discovery and resistance of antibiotics’ Antibiotic discovery has improved treatments for infectious diseases, but resistance remains a concern. Understanding sensitivity and resistivity of bacteria is crucial for understanding antibiotics&; selectivity, therapeutic index, and categorization. Developing naturally produced antibiotics is essential due to limited production.
22.Nicholas A. Church, et. al, (2021) performed a study on ‘Antibiotic resistance crisis: challenges and imperatives’ multi-drug-resistant bacteria such as Mycobacterium tuberculosis and Staphylococcus aureus are the main cause of antibiotic resistance, a worldwide problem that affects both developed and developing nations. The most frequent cause of hospital-acquired infections is the ESKAPE group of bacteria, which are resistant to strong antibiotics. New antibiotic compounds are the main focus of current research, but there is also a need for substantial changes in consumer and healthcare practices. The goal of the proposed thesis research project is to create new antibiotic compounds, grow from past errors, and enhance therapeutic approaches.
23.Yamini Javvadi, et. al, (2024) did a study on ‘Temporal dynamics and persistence of resistance genes to broad spectrum antibiotics in an urban community’. This study analyzes 13 mobile genetic elements (MGEs) and 123 antibiotic resistance genes (ARGs) in wastewater from an urban community using quantitative real-time PCR. According to the study, about half of the tested ARG subtypes were reliably found throughout the year, with winter seeing the highest abundance. Additionally, the study discovered that resistance to third and fourth generation β-lactam, aminoglycoside, tetracycline, and multidrug classes can be imparted by clinically significant genes and other variants, which greatly contributes to core/persistent resistance. In order to maintain efficacy, this information can help direct AMR control policies and encourage the prudent use of antibiotics and other antimicrobials.
24. Richard James Mabilika, et. al, (2022) did a study on ‘Prevalence and predictors of self-medication with antibiotics in selected urban and rural districts of the Dodoma region, Central Tanzania: a cross-sectional study’. Self-medication with antibiotics (SMA) contributes to the global health threat of antibiotic resistance. According to a study done in Central Tanzania's Dodoma region, SMA affected 23.6% of respondents in rural areas and 23.4% of respondents in urban areas. Amoxicillin was the most often used antibiotic. SMA was found to be 16.3% less common among urban participants and 58.9% less common among rural participants who reported a shorter perceived distance to a healthcare facility. In urban areas, farmers' SMA was 17.3% lower than that of nonfarmers, whereas farming had no effect in rural areas. In order to fight antibiotic resistance, the study emphasizes the necessity of improved access to healthcare and preventative measures.
25.Prarthan Kn et. al, (2024) An international health concern, antimicrobial resistance (AMR) is brought on by the overuse and misuse of antibiotics. 75.6% of participants in a study conducted in Dakshina Kannada, India, were aware of AMR, with medical professionals serving as the main information source. But alarming practices like antibiotic abuse—such as taking antibiotics without a prescription and stopping treatment too soon—continue. The study emphasizes the necessity of focused educational programs to encourage appropriate antibiotic use and lessen the risk of AMR. Potential biases from self-reported data and a sample size that might not accurately reflect the region's diverse population are among the limitations.
REFRENCES
Febin George*, Pretty Rachel Mathew, Nandhana K. R., Muhammad Fayas, A Comparative Study on Antibiotic Use and Resistance Patterns Among Urban and Rural Population, Int. J. of Pharm. Sci., 2025, Vol 3, Issue 3, 1257-1283. https://doi.org/10.5281/zenodo.15023020
10.5281/zenodo.15023020
